PTA OVERVIEW AND HARDWARE

INTRODUCTION• Endovascular revascularization of infrarenal aortic and iliac disease- high

rate of technical success and with lower morbidity and mortality than open bypass surgery

• Preferred modality for treatment of patients with Trans-Atlantic Inter-Society Consensus Document (TASC) II type A and B lesions

• Surgical revascularization preferred for patients with TASC type C and D lesions

• In contemporary practice, surgery is reserved for failure of endovascular approach

Modified TASC Morphological Classification (TransAtlantic Inter-Society Consensus)

TASC -Femoral-Popliteal Lesions

AortoIliac and Common Femoral Intervention

5 YEAR PATENCY RATES OF AORTOILIAC INTERVENTIONS

Vessel diameter

Vessel Size in mm

Infrarenal Aorta 14-20

Common Iliac 8-12

External Iliac 7-10

Common femoral 6-7

Recommendation for vascular access of aortoiliac intervention

Location of lesion Vascular access

Aortic bifurcation Bilateral retrograde CFA

Ostial common iliac Ipsilateral retrograde CFA, brachial artery

Common and EIA stenosis Ipsilateral retrograde , contralateral CFA

Common and EIA occlusion Ipsilateral+/- contralateral CFA, brachial artery

Common femoral Contralateral retrograde CFA

Common, EIA,SFA , popliteal Contralateral retrograde CFA

Vascular Access• Relatively disease-free, without signi Ca

• Over a bony structure, if possible

• Angle of entry- 30⁰-45⁰

• Obtained with an 18-gauge needle that will accommodate most 0.038 “ or smaller Wires

• A smaller 21-gauge needle with a 0.018-inch wire - “micropuncture kit” (Cook, Bloomington, IN)

• Used for difficult femoral, brachial, radial, or antegrade femoral approaches

Retrograde Common Femoral Artery Access• Common access site used for

peripheral diagnostic angiography and intervention

• Prevent injury to the less diseased extremity

Contralateral femoral retrograde access

• iliac occlusions are best treated from a contralateral approach

• SFA,PFA- lesions OF CFA/involve SFA/PFA ostium -

• allows treatment B/L disease with a single arterial puncture

Femoropopliteal Artery Intervention

• Contralateral femoral retrograde access :

Advantage Disadvantage

Less subsequent complications including hemorrhage from puncture site

Working from a distance with exchange-length wires and balloons

Ability to image CFA and its bifurcation Lack of support while traverse of critically narrowed or occluded sites

Ability to treat iliac and infrainguinal disease in the same setting

Antegrade Common Femoral Artery Access

• Required for infrainguinal proced• Approx 3cm CFA lies betw ligament &

FA bifurcation • Inorder to access CFA, skin entry-

prox to ing ligm • Access too close to F bifurc –inadeq

working room to selectively cath SFA

Ipsilateral popliteal retrograde access

• Useful in SFA occlusion with failure to cross from contralateral or antegrade

• Ostial SFA/CFA lesions may also be approached via PA in acute angled terminal ao bifurc

• CI- aneurysms of PA, pathology of popliteal fossa- Baker’s cyst

Brachial Artery Access

• Pref access for visc arterial [CA, SMA] interventions

• PC approach at BA can lead to a ↑compli rate– UL arts – smaller, prone to spasm – A small hematoma- Could lead to brachial plexopathy

• Itv req >6F sheaths/smaller pt→open approach preferred

• Left BA access pref over Rt- can avoid carotid origin

• A micropuncture tech should be used for all PC BA intervention

• Left brachial approach has approximately 100mm greater reach than the right brachial approach

Estimated distances from FA access

GUIDEWIRES

• Guidewires are used to introduce, position, and exchange catheters

• In a standard guide wire, a stainless steel coil surrounds a tapered inner core

• A central safety wire filament is incorporated to prevent separation in case of fracture

• 5 charecterstics- size, length, stiffness, coating, and tip configuration

• Typically they are 100 to 120 cm in length but can also be 260 to 300 cm(good rule of thumb to follow is that the guidewire should be twice the length of the longest catheter being used)

• Tip of the wires can be straight, angled, or J-shaped

• Varying degrees of shaft stiffness- extra support,to provide a strong rail to advance catheters in tortuous anatomy vs extremely slick hydrophilic with low friction

Wire selection

• Diameter vary from 0.014“ to 0.038“

• Most commonly used size is 0.018“/0.035“ ( upper extremity) and 0.014“/ 0.018“ ( lower extremity)

• Length between 130 and 300cm

• Tip configurations are; straight, angled Tip and J shape

• Varying degrees of shaft stiffness ( e.g. extra support, super stiff wires) allow advancement of stiff devices

Hydr-angle tip–Glidewire

Can be used for crossing tight lesions and can be advanced independent of a guidewire038:18g needle, 018:21g needle

Guidewire-Lesion Interaction

• Floppy portion moving in a linear fashion• Floppy portion piles up prox to lesion—no chance

to cross- backup,redirect,if straight tip→steerable• Floppy tip bent with min R—Cautiously adv wire-

once crossed, wire should straighten- advancing a “buckledup” wire- force→embolization

• Floppy tip “buckledup” —backup,redirect,adv -dissect,embolz,wire damag

Guide wire FunctionsPTA Guidewires are designed to:

• Track through the vessel– Access a lesion– Cross a lesion– Provide device delivery support

PTA Guide wires

Coils & covers

Outer coils

Tip coils only

Polymer cover

Polymer sleeve Tip coils

Coils & covers

•Coils provide tactile feedback, radiopacity and maintain constant overall diameters

• Polymer covers/sleeves provide optimal lubricity to overcome resistance and access to the lesion

Allows smooth tracking through tortuous anatomy

Better device tracking over the guidewire

Not to be confused with coating (hydrophilic or hydrophobic)

Covers and Coatings – Summary

Lubricity

Delivery &Device Interaction

Tactile Feedback (related to coils)

NoCoating

HydrophobicCoating

Hydrophilic Coating

Polymer Cover with hydrophilic Coating

PTA GUIDE WIRES

• Glidewire (TERUMO)Peripheral Guidewires

(0.032"-0.038")Standard GlidewireShapeable Tip GlidewireLong Taper GlidewireStiff Shaft GlidewireStiff Shaft Long Taper Glidewire1 cm Taper GlidewireJ-Tip GlidewireBolia Curve GlidewireGlidewire Advantage™

Small Vessel Guidewires(0.018"-0.025")

Glidewire Standard and Shapeable TipGlidewire GT Super-SelectiveGlidewire Gold

•Terumo Glide Technology™ hydrophilic coating

smooth, rapid movement through tortuous vessels crossability over difficult lesions

•Core-to-tip design provides 1:1 torque ratio

•elastic nitinol core for optimal performance

•Resists kink &Retains shape

•Tungsten in polyurethane jacket- radiopacity

•Carries the risks of vessel dissectionand perforation

•should not be used to traverse needles because of the potential of shearing

ABBOT

Hi-Torque Steelcore Peripheral Guide Wire (190/300 cm)

Hi-Torque Spartacore Peri Wire

• Excellent .014" Support SS shaft• Superb Steerability and a Soft

Shapeable Tip• Core-to-tip design• 130/190/300 cm lengths• MICROGLIDE Coating• PTFE up to distal 7 cm (130 cm)• Available in 5 and 10 cm

Hi-Torque Supra Core 35

• One-to-one torque• exceptionalsteerability• MICROGLIDE coating• Radiopaque tip• 035" shaft• Soft Shapeable tip

Hi-Torque Versacore Guide Wire

• Torqueable wire for deliverability through tortuous or challenging lesions

• Soft shapeable tip designed to for lesion acces

BOSTON SCIENTIFIC

Amplatz Super Stiff Guide Wire• For stiffness, strength and

stability during catheter placement and exchange

• Diameters: 0.035", 0.038"

• Lengths: 145cm,180cm, 260cm

• Tips Styles: Straight, J, Short

• Core Material: Stainless steel

• Coating: PTFE

Magic Torque Guide Wire• Magic Markers spaced at

1cm increments

• designed for enhanced visualization and excellent torque control

• Diameters: 0.035"• Lengths:180cm, 260cm• Tips Styles: Straight

(shapeable)• Core Material: Stainless

steel• Coating: Glidex Hydrophilic

Coating (tip)

Meier Guide Wire• Stiff shaft excellent

supp • flexible tip is ( AAA

endovascular graft procedures)

• Diameters: 0.035"• Lengths: 185cm, 260cm,

300cm• Tips Styles: J, C• Core Material: Stainless

steel• Coating: PTFE

Platinum Plus Guide Wire• Designed for negotiation

of tortuous anatomy and contralateral approaches

• Diameters: 0.014", 0.018", 0.025"

• Lengths (cm): 60, 145, 180, 260, 300

• Tips Styles: Straight – Long or short taper

• Core Material: Stainless steel

• Coating: Glidex Hydrophilic

Thru way Guide Wire

• Designed for excellent performance in acutely angled vessels, such as renals and other peripheral interventions

Diameters: 0.014", 0.018"• Lengths (cm): 130, 190, 300• Tips Styles: Straight, J• Core Material: Stainless steel• Coating: Silicone

CORDIS

• EMERALD™ Guidewires• Fi xed-Core, PT F E Coated, Exchange Wires

COOK Amplatz Stiff Wire Guides

• Stiff shaft • Gradual transition to a very

flexible distal tip

– TFE Coated Stainless Steel-035,038: 145,180,260-straight

– TFE Coated Stainless Steel with Heparin Coating-035: 145,180,260-straight

• 8 cm-flexi tip

Amplatz Extra-Stiff Wire Guides

• ↑ inner diameter -extra-stiff + tip flexibile

– TFE Coated Stainless Steel-025,035,038: 80,145,180,260-straight & curved:

– 300-straight

– TFE Coated Stainless Steel with Heparin Coating-035: 80,145,180,260-straight & curved

Amplatz Ultra-Stiff Wire Guides• The increased inner diameter of the wire

guide coil allows utilization of an ultra-stiff mandril while maintaining tip flexibility

– TFE Coated Stainless Steel-035,038: 80,145,180-straight

– TFE Coated Stainless Steel with Heparin Coating-035: 145,180-straight

• 8cm-flexi tip

Roadrunner Extra-Support Wire• Complex diagnostic/interventions - where extra support needed for cath exchange

/manipulation of devices

• Heavy-duty nitinol alloy mandril provides support while imparting 1:1 torque response to distal platinum spring coil tip

• Angled tip facilitates directional control• Lubricious TFE coating -low coefficient of friction

• 014,018• 180,270,300

Cope Mandril Wire Guides I

• Stainless Steel

• Platinum coil ↑visualization and an angled floppy tip for precise directional control

• 018

• 40,60,100,125

• Standard taper-7cm coil

Cope Mandril Wire Guides II

• Nitinol kink resistant 1:1 torque control• Platinum coil -↑visualization

• angled floppy tip for precise directional control

• 018

• 60,100,125

• Standard taper-7cm coil, short taper-7cm coil

Rosen Curved Wire Guides

• The heavy-duty mandril, 2 cm flexible tip and tightened “J” configuration

• Ideal for Renal int- less traumatic

• TFE Coated Stainless Steel-035: 80,145,180,220,260

• TFE Coated Stainless Steel with Heparin Coating-035: 145,180,260

The Graduate Measuring Wire Guides• Used to determine accurate sizing of vessel • Gold radiopaque markers delineate 25 cm length• Six distal markers are spaced 1 cm apart.• Four proximal markers are spaced at 5 cm increments.• 035• 145,180

Reuter Tip Deflecting Wire Guide• Used with Reuter Tip Deflecting Handle for curving or

deflecting catheter tips during selective and superselective angiography

• Facilitates catheter tip movement by controlling the deflection of the wire guide tip within catheter lumen

• Distal tip of wire guide must never extend beyond tip

BIOTRONIK

Cruiser Guide Wire• 0.014“• L: 190 cm• Tip Shape: Straight and J

Cruiser-18

• Hi-support Guide Wire

• 0.018”

• Stiff: 195 cm and 300 cmMedium: 195 cm and 300 cm

Catheter

An “ideal catheter” should be able to sustain high-pressure injections, to track well, be nonthrombogenic, have good memory, and should torque well

Catheter ( diagnostic/ guiding)Length depends on location for usingSizes are 5 to 8 French

a) abdominal aorta = 60 to 80 cm length

b) BTK,carotid or subclavian areas 100 to 125cm length

Polyethylene- ↓coef friction, pliablePolyurethane- softer, even ↑pliable→ tracks wires betterNylon- stiffer, can tolerate ↑flow rate- amenable to angioTeflon- stiffest- used mainly for dilators & sheaths

wire braid in the wall to impart torquibility and strength

Guiding Catheter vs Sheath• Operator dept

• Sheaths are designed with a simple diaphragm or a hemostatic valve, guiding catheters always require hemostatic valves be attached

• During intervention, the guide catheter or sheath should be placed near the lesion to provide for better visualizationand improved support

Flush /Non-Sel Selective CATHETERS

BALKIN Sheath (cook)

• Contralateral access to the iliac artery

• Flexibility without kinking or compression

• Radiopaque band- identifies precise location of sheath’s distal tip for positioning accuracy

• The Check-Flo valve prevents blood reflux and air aspiration during catheter manipulations

• 5.5 Fr-8 Fr- 40cm - .038” compatible

Super Arrow-Flex® Sheath /Dilator Setwith 90° curved tip (ARROW International)

• 6-7Fr• 45cm length Assures successful access to the renal arteries. “Y”

Connector + Tuohy Hemostasis Valve a+ 3-Way Stopcock• 90° Curved Tip Both sheath and dilator have a curved tip for easy access

to the renal artery• Sheath replaces guide catheter -eliminates the need for using a guiding

catheter - reducing size of puncture• Radiopaque tip marker-locate and control sheath advancement into RA

TERUMO GUIDING SHEATH( Pinnacle Destination)

• Guiding Sheaths (5-8 Fr)

• 5-8 F• 45,65,90• Hydrophilic coating• All dilators are 0.038" wire compatible

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TERUMO• Glidecath (4 Fr)-65,100,120-038• Glidecath XP (5 Fr)-65,100-038 • Glidecath (5 Fr)-65,100-038

TERUMO GLIDE CATH• Hydrophilic Coated Catheters• Hydrophilic coated distal tip (15 cm) for smooth passage through tortuous

vasculature

• Double-braided stainless steel mesh middle layer ↑ shaft rigidity and torque transmission

• Nylon-rich polyurethane inner layer for smooth flow of therapeutic agents and 0.035"/0.038" embolization coils

• Large lumen (0.038" wire compatible) and small profile (4 Fr) is ideal for:

Use as a guiding catheter for microcatheters

Diagnostic procedures that require high flow rates

Excellent trackability and navigation –most tortuous anatomies

SOS Omni selective catheter• Soft, atraumatic, Super-radiopaque tip • Reforming in desc thoracic aorta – below great

vessels rather than transverse arch –safety• Pulled from the desc ao into abd ao with a floppy

guidewire “leading,” sometimes with a rotating motion

• Soft, flexible atraumatic tip can be placed deeper into the artery (>1 cm), ↓chance of “catheter kickout.”

• Shaped tip allows the guidewire to flick into the origin of the RA

Omni Flush Angiographic Catheter• Flush aortography B/L“run off” studies of LL• Cross ao bifurcation with ease for C/L diagnostics in

interventional procedures• Super-Radiopaque tip• Reforms and maintains shape—even under injection

pressure—with less catheter whipping-less vessel wall injury

• Less contrast reflux than other flush catheters-lower total contrast dose

• 4F IMPRESS Simmons 1 Catheter 65cm..038

• Side Ports:N/A• Catheter Shape:SIMMONS

1• French Size:4

• 5F IMPRESS Simmons 2 Catheter 65cm..038

• Side Ports:N/A• Catheter Shape:SIMMONS

2• French Size: 5

Microcatheters (TERUMO)

• Progreat™ (2.4 Fr, 2.7 Fr)- 110/130- OD 2.9Fr/2.7 • Progreat™Ω (2.8 Fr)- 110/130- OD 3Fr/2.8

Slip-Cath Beacon Tip Catheters (C00K)

• Hydrophilic Coating

• Enhanced radiopaque Beacon tip

• Sixteen stainless steel wire braid imparts 1:1 torque control to catheter tip & ↑pushability

• Nylon material resists softening during prolonged catheter manipulation

Slip-Cath Beacon Tip Catheters

CXI Support Catheters(C00K)

• For use in small vessel/superselective anatomy for diagn & interv procedures, incl peripheral use

• Low profile from tip to hub ensures smooth transition through small vessels

• Shaft's polymer material offers desired flexibility

• Braided SS entire length -pushability

• Hydrophilic coating

• Embedded radiopaque markers -size the vessel segment length

Veripath Peripheral Guiding Catheter(ABBOT)

• Three-Layer Construction• 50 cm length• 5 catheter shapes• 6,7,8 F• 014/018

• CORDIS

Accesses and Selective Guiding Catheters for Some Basic Interventions

Carotid Artery1.First choice access—either FA2.Alternative access—left BA3.Selective catheter—Right carotid: H1,Simmons,VitekLeft carotid : angled glidecath,H1,Simmons

Subclavian Artery1.First choice—either FA2.Alternative access—ipsilateral BA3.Selective catheter– angled Glidecath,H1,Simmons,H3

Celiac or SMA1.First choice—either FA2.Alternative access—left BA3.Selective catheter—RIM,Chuang

Renal Artery1.First choice—contralateral FA2.Alternative access—left BA3.Selective catheter—C2,RDC,Sos-omni

Infrarenal Aorta1.First choice —either FA2.Alternative access—left BA3.Selective catheter—omni-flush,RIM,C2

Superior Femoral Artery1.First choice—contralateral FA2.Alternative—ipsi retro FA for run-off; ipsi antegrade for interv3.Selective catheter—Berenstein,Kumpe,Vertebral

Tibial Arteries1.First choice—contralateral FA2.Alternative—ipsi retro FA for run-off; ipsi antegrade for interv3.Selective catheter—Kumpe,Vertebral

Vessel size• The vessel in each territory have their own different size,

important to know to choose a proper balloon or stent

Balloons

Balloons

• In selecting a balloon, the following criteria should be considered : a) Guidewire ( 0.014“, 0.018“, 0.035“) b) Over the wire (OTW) or monorail system c) Shaft length

• Balloon shaft lengths are commonly 75 cm or 120 cm, can be coaxial or monorail and designed to be inserted over 0.014-in., 0.018-in., or 0.035-in. wires

• 0.014“ balloon system is usually for carotid, vertebral, renal, infrapopliteal arteries

• 0.018“ balloon system also in SFA, infrapopliteal- operator dept

• 0.035“ balloon system for subclavian, innominate, aortoiliac, superficial femoral artery

• Circumfer force/tension (T) exerted on wall of an inflatd balln ~P within balln & R (T=P×R)(LAPLACE)

• Larger ballns -require ↓P than smaller ballns to generate substantial dilating forces

• Larger vessels (Ao) require ↓P to dilate & rupture

1. Diameter matching vessel beyond lesion2. Balloon length should be > lesion3. Balloon centered on lesion & inflated slowly4. Inflation maintained for 20s- deflated- reinflated 3 inflations of 20s

• Patient’s complaint of low back pain during balloon inflation may be a warning sign of adventitial stretch, which may occur before aortic rupture

ATB ADVANCE PTA Dilatation CatheterAdvance 14LPAdvance 18LP

Advance 35LP (C00K)

• Designed for iliac, renal, popliteal, infrapopliteal, femoral and iliofemoral

• Also intended for postdilatation of balloon-expandable peripheral vascular stents

• 40,80,120• Low profile• Hydrophilic

Advance 14LP (C00K)

• Low Profile • Provides the trackability and pushability to reach

even the most remote infrapopliteal lesions• Hydrophilic coating on balloon and distal shaft,

along with a smooth tip transition• Maintains super-low profile after inflation• 4 Fr sheath compatibility for all sizes• 20 to 200 mm in 2, 2.5, 3, 4 mm D• 170

FoxCross .035 PTA (ABBOT)

• D-(3-14 mm), L-(20-120 mm), and cath L (50, 80 &135 cm)-OTW

• Good trackability, rapid inflation/deflation• Crossability -useful in calcified lesions• 5-7 F• Guide wire compatibility: 035• Nylon Polymer• JETCOAT coating

ABBOT

Fox sv PTA Catheter

• OTW designed for challenging small vessel procedures

• Range of BTK and SFA sizes (2-6 mm) 90,150

• Sheath Compatibility:4F for all sizes

• Guide wire compatibility:.014"/.018

Fox Plus PTA Catheter

• Low Profile• Compatible with a 5 Fr

sheath up to 7mm balloons

• Shaft Technology-dual lumen-Rapid infl and deflation

• JET coated - Reduces friction and facilitates access and crossing of target lesions

Sterling Balloon Dilatation Catheters(BOSTON SCIENTIFIC)

• Breakthrough 4F Profile

• Both Over-the-Wire and rapid exchange

• 40,80,135

• Specifically designed for use in carotid, renal and lower extremity arteries

• Sterling SL Balloon Dilatation Cath

• long lengths-BTK - specifically designed - infrapopliteal procedures

• 014, 018

• OTW and Monorail

• 90,150

• Sterling ES Balloon Dilatation Cath

• 0.014" balloon cath

• Ultra-low profile balloon

• Both OTW and rapid exchange platforms

• .017" tip entry profile

• 140

BIOTRONIK

Passeo-18Passeo-35

• Balloon Catheter 0.018” /.035” OTW

• Hydrophobic patchwork coated balloon ensures a smooth crossing through tortuous

vessels and across high grade stenosis whilst minimising the risk of slippage during inflation experienced using hydrophilic coated balloons

Stentsa) Balloon-expandableb) Self-expandablec) Stent graft

Balloon-expandable stents• Require positive pressure for expansion

• Typically rigid with high radial force

• Size of the balloon-expandable stent equals to the size of the reference vessel diameter

• Ideal for immobile sites of the body subclavian, renal, mesenteric, iliac arteries and at

ostial locations

PALMAZ Bal-Exp Stent (unmounted)CORDIS

• Closed cell• SS• Stent D (Expanded) 4-8mm• Stent L (Unexpanded) 10,15,20,29,39mm• Sheath Introducer 6F, 7F

Dynamic Renal (BIOTRONIK)

• Balloon-Expandable Cobalt Chromium Stent 0.014” / Rx

Dynamic

• Balloon-Expandable Stainless Steel Stent 0.035” / OTW

SELF EXPANDABLE Stents• Deployed in vessels that are flexible or twist during movement of

neck, shoulder or leg Carotid, Axillary, SFA, Popliteal artery• Nitinol - metal - provides best flexibility and memory• Stent is simply compressed over a stent delivery catheter and

covered with a sheath• Stent deployment is achieved by pulling back the sheath • Stent diameter should be 1-2mm larger than the reference vessel

diameter- adequate stent apposition with the vessel wall

Self-expandable Stents• Some degree of foreshortening- to be taken into

account when choosing

• More difficult to place with absolute precision

• Generally comes in longer length than BES

• Their ability to continually expand after delivery allows them to accommodate adjacent vessels of different size

BX- vs SX stents for iliac interventionBX stent SX stent

Advantages High radial force Elasticity,flexibility

Minimal foreshortening Conformibility

Good visibility MRI compatibility

absolute precision continually expand – vessel size

Disadvantages Risk of edge dissection Need post-dil.

Stent crushing Suboptimal radial strength

Incomplete stent apposition Foreshortening

Artifacts on MRI Non precise

Suitable lesions Heavily calcified lesions Non-ostial common lesion

Immobile EIA; CFA -mobile

Ostial Long lesions

Decision between SE or BE stents in Iliac Lesions

• Balloon expandable– Aortoiliac bifurcation– Common iliac– Calcified lesions– Chronic occlusions (?)

• Self expanding– Vessels flexible/twist

during movement – Tortuous vessels– Distal external iliac

artery– Contralateral approach– Long diffuse lesions– Aortoiliac bifurcation

(long lesions)

Stent Grafts• Combination of a metal stent covered with fabric

• Used to exclude aneurysm, treat perforations when prolonged balloon inflation failled

• Wallgraft and Viabahn are the two options currently available for treatment of perforations of aneurysm in larg vessels

Fluency Plus (Bard) Tracheobronchial Self-expanding

Jostent (Abbott) Coronary perforation Balloon-expanded

Viabahn (Gore) SFA Self-expanding

ICast (Atrium) Tracheobronchial Balloon-expanded

EquipmentIpsilateral retrograde approach

Contralateral approach Brachial artery approach

6-8F Sheath, length 11cm or 23cm 6-8F cross- over Sheath 6-7F 90cm sheath6-7F Guiding catheter

0.035“ wire, length 180-190cm 0.035“ wire, length 180-190cm 0.035“ wire, length 260-300cm

0.035“ wire compatible Balloon catheter , diam. 6-9mm,Shaft length 75-90cm

Balloon catheter , diam. 6-9mm,Shaft length 75-90cm

Balloon catheter , diam. 6-9mm,Shaft length 130cm

BX stent, diam. 8-9mm, shaft length 75-110cm

BX stent, diam. 8-9mm, shaft length 75-110cm

BX stent, diam. 8-9mm, shaft length 130cm

SX stent , diam.8-14mm, shaft length 75-110cm

SX stent , diam.8-14mm, shaft length 75-110cm

SX stent , diam.8-14mm, shaft length 130cm

Retrograde iliac stent placement

Cross-over stent placement

Subintimal angioplasty• Hydrophilic wire not passing• Carefully adv into subintimal plane- if not

spontaneously, gentle inflation of balloon at edge of the plaque

• Wire traversed the lesion subintimaliy• Hydrophilic catheter or other re-entry device

passed OTW to guide it back into lumen• Standard angioplasty of subintimal plane

performed, with stent placement

Subintimal angioplasty

Femoropopliteal Artery InterventionFour potential routes of access to the SFA and popliteal:• Contralateral femoral retrograde access• Ipsilateral femoral antegrade access• Ipsilateral popliteal retrograde access• Brachial retrograde accessBalloon• Balloon size and length is matched to the size ( ~5-6mm) and lesion

length( ~40- 300mm) of SFA• Improved angiographic results may be accomplished with

prolonged inflation times ( 3-5 minutes)• Dissections are commonly seen after balloon dilation ( due to heavy

calcification)

Femoropopliteal Artery Intervention Stent implantion ( always SX-Stents):

• Sizing the SX- stent ~ 1mm greater than the RVD of SFA• Postdilation with 5.0-6.0 mm diameter balloon

• Popliteal artery -> avoid stent = high risk of stent compression or fracture

SX-Stent problems:

• Stent fracture -especially in stent overlap

• “ In-Stent-Restenoses“-in long stented segments, multiple stents

• DEB

Five-year patency (%) of femoral popliteal revascularization

Outcome

Kasapis C, et al Eur Heart J. 2009;30:44- 55

Infrapopliteal Intervention

4 anterior tibial artery5 tibio-peroneal trunk6 posterior tibial artery6a peroneal artery6b perforating branch of the peroneal artery6c communicating branch of the peroneal artery7 dorsalis pedis8 medial plantar artery9 lateral artery10 plantar arch

Vascular Access•Cross- over technique ( retrograde access)•Ipsilateral antegrade access ( recommended)•Retrograde pedal access•Brachial access•Radial access

wire selectiononly atraumatic 0.014“ / 0.018“ guide wires should be used0.014“ prefered due to vessel diamet( floppy, medium,stiff)

Balloon AngioplastyLow profile balloon with high pushability and trackability Vessel conformabilityFlexibility in small collateral branches 0.014”/ 0.018" wire compatibilityDiameter 1.5mm-4.0mmLong (20-210 mm)& tapered tip to reduce procedure times and dissection

Infrapopliteal- Stent implantationRequirements - BTK BE-Stents

• “PTA balloon like” flexibility• Ultra-low profile and extreme flexible delivery system with 0.014”

guidewire compatibility• 2 - 4 mm stent delivery system diameter • Long stents ( up to ~ 80mm)• 4F introducer sheath compatibility • braided sheath design - pushability and flexibility to enable easy

negotiation in tortuous anatomies without kinking

Infrapopliteal Intervention-EquipmentContralateral approach Antegrade Approach

5F-6F cross-over-sheath, 55cm or 70cm 4F-6F short sheath

0.035“ 300cm wire 0.035“ 190cm wire

5F-6F Guiding catheter, if no long sheath is used 5F-6F Guiding catheter, if no long sheath is used

0.014“-0.018“ wire ( 0.014“ prefered) 0.014“-0.018“ wire ( 0.014“ prefered)

Balloon catheter, 1.5-4.0mm diameter, length 20mm-210mm, shaft length 150cm

Balloon catheter, 1.5-4.0mm diameter, length 20mm-210mm, shaft length 120cm

0.014“ balloon expandable stent, 150cm shaft length 0.014“ balloon expandable stent, 120cm shaft length

0.014“-0.018“ self-expandable stent, long shaft 0.014“-0.018“ self-expandable stent, short shaft

Guide wire support catheter ( facilitate wire Crossing)

Guide wire support catheter ( facilitate wire Crossing)

• Limb salvage rate is high, but restenoses rate also high

• Restenoses rates ~ 70% @ 3 months- depends on severity of disease

Efficacy of Coronary DES in Infrapopliteal Arteries

Advances in Treatment of AortoiliacOcclusions

• Inability to cross an occlusion with a guidewire or to reenter the true lumen beyond the occlusion remains the most common cause for technical failure

1. Front Runner device2. Crosser catheter3. Reentry devices

• The Frontrunner® (Cordis) or Quickcross® catheters are designed to maintain the wire in the center of the lumen and penetrate the plaque and/or thrombus in a controlled fashion

Subintimal dissection plane• buckling a glide wire the subintimal plane is entered• Following with an angled glide catheter-re-enter the lumen

distal to the obstruction• This step is the limiting factor • Adjuncts - Outback® or Pioneer® catheter which allow an

angled needle to puncture back into the true lumen

FRONTRUNNER® XP CTO Catheter (cordis)• Enables controlled crossing of CTOs using blunt microdissection to create

a channel through the occlusion to facilitate wire placement.

• Low profile. Features a crossing profile of .039" with actuating jaws that open to 2.3 mm.

• Hydrophilic coating along the entire catheter length to facilitate crossing• Catheter steerability.- shapeable distal tip + effective torque control

enhance maneuverability and catheter steerability• No guidewire lumen.Variable support from advancing and retracting the

4.5F Micro Guide Catheter.

CROSSER Catheter (Flow Cardia Inc, Sunnyvale, Calif)• High-frequency mechanical vibrations (20, 000 cycles/ second to a depth

of 20 µm) propagated through a nitinol core wire to a stainless steel tip• A generator, transducer, foot switch, and disposable catheter• Generator applies AC current to the piezoelectric crystals in the transducer• Vibrational mechanical impact and cavitational effects - penetration • 1.1 mm in diameter, monorail, and hydrophilic• Can be mounted on a standard 0.014” guidewire• Compatible with a 6F guiding catheter• Vessel size- a minimum diameter of 2.5 mm is recommended

cordis

• Low profile, 6F sheath compatible• Highly visible "L" and "T" markers. Orient the re-entry cannula

toward the true lumen easily, eliminating the need for additional visualization equipment

• Effective torque control• On average 8 minutes to gain re-entry (↓ procedure time)• Lubricious, hydrophilic coating along the entire catheter

length to facilitate subintimal passage• Easy to use

OUTBACK CATHETER (J&J, Cordis, New Brunswick, NJ, USA)

Pioneer reentry catheter (Medtronic)

• Distal 25-gauge nitinol reentry needle• 64-element phased-array IVUS transducer• 120 cm long• accomm -2 -0.014”guidewires (1 to track the device and 1 for the reentry needle)• Compatible with a 7F sheath

• The device is brought into the subintimal tract over a wire, and under intravascular ultrasound imaging, color flow is identified in the true lumen

• The catheter is rotated to position the true lumen at the “12

o’clock” position, after which the needle is advanced and the true lumen is wired

Advances in Balloon Angioplasty-BasedApproaches

1. Drug-coated balloons

2. Cryoplasty

3. Cutting balloons

• Paclitaxel is the most commonly used agent for drug-coatedballoons (DCBs)

• high local drug conc and • # neointimal proliferation -brief exposure • had lower late loss and angiographic

restenosis at 6-month follow-up (17% vs 44% in the Thunder study; 19% vs 47%in FemPac)

Drug-coated balloons

• Occlusion,containement &Perfusion therapy• low pressure balloon infusion maximizes drug penetration locally within the

vessel• B-L/10-50mm,DM-1-4mm• 134cm-Rapid ex• 40,80,90,140 cm -OTW

Cryoplasty (PolarCath, Boston Scientific)

• Combines angioplasty with simultaneous delivery of cold thermal energy to the arterial wall

• liquid nitrous oxide - balloon inflation/ cooling - 10°C• MOA-plaque modification, reduction of elastic recoil, and

induction of apoptosis in the smooth muscle cells -↓ dissection and need for stenting

• Insufficient data to support its routine use

Advances in Stent Technology

• Drug-eluting stents

• Nitinol self-expanding stents

• Bioabsorbable stents

• Nitinol stent grafts and covered stents

(cook)• The Zilver PTX Drug-Eluting Stent is a self-expanding stent made of nitinol

and coated with the drug paclitaxel

• It is a flexible, slotted tube that is designed to provide support while maintaining flexibility in the vessel upon deployment

• The stent is preloaded in a 6.0 French delivery catheter

• 0.035 inch wire

• recommended for use in above-the-knee femoropopliteal arteries having reference vessel diameter from 4 mm to 9 mm

• Zilver PTX ( Cook) showed good results in TASC A/ B lesions(RESILIENT STUDY)

COOK

Zilver 518 • Vascular Self-Expanding

nitinol Stent- iliac arteries

• Recomm 5.0 Fr sheath/7.0 Fr guiding cath

• Accepts .018 inch wire

Zilver 518 RX• Vascular Self-Expanding

Nitinol Stent – Rapid Exchange-iliac

• Recommended 5.0 Fr sheath/7.0 Fr guiding catheter

• Accepts .018 inch diameter wire guide.

Zilver 635

• Vascular Self-Expanding Nitinol Stent

• Recommended 6.0 Fr sheath/8.0 Fr guiding catheter size

• Accepts .035 inch diameter wire guide

Absolute Pro LL Peripheral Self-Expanding Stent (ABBOT)

• 035• designed to treat longer SFA lesions• 120,150

Absolute Pro LL

Xpert Self-Expanding Stent(ABBOT)

• 4F compatible -speci designed for small vessels

• Peri vessels from D 2-7 mm• 018• Nitinol• low strut profile• Conformability

Self-Ex: S.M.A.R.T. CONTROL Iliac(cordis)

• MicroMesh Geometry, Segmented Design

• Nitinol

• 12 Tantalum MicroMarkers define stent ends for easy visualization and placement

• Stent D 6-10, 12, 14mm (should be 1-2mm >vessel D)

• 80,120 cm

• Maximum Guidewire .035"

• Sheath Compatibility 6F (6-10mm), 7F (12-14mm)

• Guide Compatibility 8F (6-10mm), 9F (12-14mm)

4-year follow-up patency rates• 79% TLR free after 4 years• 59% Binary Restenosis free after 4 years (lowest published)

Self-Ex: PRECISE Carotid Stent System(cordis)

• MicroMesh Geometry, Segmented Design• Nitinol• Stent D 5-10mm• 135cm, Over-the-Wire• Maximum Guidewire .018"• Sheath Compatibility 5.5F (5-8mm diameters), 6F

(9-10mm diameters)• Guide Compatibility 7F (5-8mm diameters), 8F (9-

10mm diameters)

Self-Ex: PRECISE PRO RX Carotid Stent (cordis)

• MicroMesh Geometry, Segmented Design• Nitinol• Stent Diameters 5-10mm• 135cm, Rapid Exchange• Maximum Guidewire .014"• Sheath Compatibility 5F (5-8mm diameters), 6F

(9-10mm diameters)• Guide Compatibility 7F (5-8mm diameters), 8F (9-

10mm diameters

Astron-biotronik

• Self-Expanding Nitinol Stent 0.035” / OTW

Astron Pulsar-Biotronik

• Self-Expanding Nitinol Stent OTW

• For treatment of diseases of femoral and infrapopliteal arteries.

• Self-expanding stent to the peripheral vasculature via a sheathed delivery system

• intended to improve luminal diameter in the treatment of symptomatic de-novo or restenotic lesions up to 240 mm in length in the native superficial femoral artery (SfA) and proximal popliteal artery with reference vessel diameters ranging from 4.0-6.5 mm.

Covered Stents

GORE

Jostent Peripheral Stent Graft (Abbot)

• High grade surgical stainless steel 316L PTFE Graft material• Recommended minimum sheath size- introducer size that is

two sizes larger than the sheath size

• Wall thickness after expansion Standard version: 0.40 mm Large version: .45 mmMinimal crimped outer diameter Standard version: 2.3 mm = 7F Large version: 2..7 mm = 8F

• Minimal deployment pressure 4 bar

KYOTO-MED GP-JAPAN

• Biodegradable polymer PLLA (poly-L-lactic acid)• characteristics of being dissolved into water and carbon dioxide and

absorbed into vessel tissue within a few years after implantation

• metal allergies or pats who are still growing

• will not interfere with other procedures such as restenting/Sx

• More useful for containing drugs compared to metal stent- intended as a platform for drug eluting stents.

Advances in Plaque Removal or Debulking

• Excimer laser

• Excisional and rotational atherectomy

Excimer laser• The 308-nm excimer laser -fiberoptic catheters to deliver intense bursts of

ultraviolet energy in short pulse durations• The adv of uv light – short penetration depth of 50µ m break molecular bonds directly by a photochemicalprocess ability to ablate thrombus and to inhibit platelet aggregation.

• Removes a tissue layer of 10 µm with each pulse of energy.• Ablated only on contact without a rise in temp to surrounding tissue

• Ability to treat long occlusions and complex disease

SilverHawk Plaque Excision System (Fox Hollow Technologies)

cutter blade (long arrow) luminal plaques (small arrow)

Plaques are excised (double arrows)

High-speed cutting blade excises a ribbon of plaque that is collected into the catheter nose cone. 7 different sizes

monorail catheters meant for rapid exchange and operate over a 0.014-inch diameter wire system

ROTATIONAL ATHERECTOMY DEVICES

Pathway Medical PV system (Pathway Medical Technologies,Redmond, Wash)

expandable, rotating scraping blades (“flutes”)

ports between the flutes that allow flushing and aspiration of plaque material/thrombus

The Orbital Atherectomy System (Cardiovascular Systems,St Paul,

Minn)

high-speed rotational atherectomy system eccentric, diamond-coated abrasive crown

When rotated at high speeds, the abrasive crown

moves in an orbital path within the artery, potentially creating a lumen larger than the diameter of the crown

BRIDGING THE GAP: ROLE OF HYBRIDPROCEDURES

• Multilevel peripheral arterial occlusive disease

• Older patients with several comorbidities

• Common examples of hybrid procedures include common femoral artery endarterectomy combined with angioplasty of the iliac or SFA

• Comparable outcomes to open surgical procedures, but with decreased length of stay, morbidity, and mortality

Hybrid procedure for CFA/SFA dis

THANKYOU

Antegrade puncture of the patent popliteal artery and successful crossing of the native SFA

Vascular Access

“SAFARI” Technique (Subintimal Arterial Flossing with Antegrade–Retrograde Intervention)

• Useful for completing subintimal recanalization when there is failure to re-enter distal true lumen from antegrade approach or limited target artery available for re-entry

• Technique improves technical success with subintimal recanalization

• Limb salvage rates comparable to those with antegrade subintimal recanalization

Below the Knee Tools

Stiff, steerable guidewire Stiff, steerable guidewire

Infrapopliteal PTA Balloon Catheter OTW 0.014”

Infrapopliteal Co-Cr Stent System OTW 0.014”

Infrapopliteal 0.014” Guidewire

Infrapopliteal self-expanding Stent System OTW

CrossabilityCrossability

Crossing occlusionsAvoiding abrasion, damage and risk of dissection

Crossing occlusionsAvoiding abrasion, damage and risk of dissection

Bail-out situationsBail-out situations

Dedicated long stent systemsDedicated long stent systems

Low-profile OTW balloon with suitable sizes in balloon length and diameter.LONG BALLOONS

Low-profile OTW balloon with suitable sizes in balloon length and diameter.LONG BALLOONS

Drug eluting BalloonDrug eluting Balloon Restenosis preventionRestenosis preventionPaclitaxel-eluting PTA

balloon catheter